Yvonne Rice Fertility, Surgery

Endometriosis is TREATABLE!

Endometriosis is one of the most misunderstood (and mistreated) diseases in Gynecology and maybe medicine in general. The following discussion aims to explain our professional experience with this disease over the last 15 years where we took a special interest in the disease and its management. Our perspective is very different than what is conventionally believed. What is contained in this handout is not written anywhere else and we recommend that you save this for future reference. If you’ve been given this handout, you probably have now undergone or are planning laparoscopy with excision of endometriosis. So what does this mean for you?

Our surgical treatment method is complete excision that still, even today, is very unusual. There are fewer than 25 Gynecologists in the US that do extensive excision surgery for endometriosis. The reasons for this relates very much to history and the advent of laparoscopic technology. From 1900 – 1975, all surgery for endometriosis was through an open incision like that for a hysterectomy. The treatment technique, though, was excision. There are numerous studies during that time period that showed 80+ % long term success for pain relief. This is compared to many laparoscopic cautery studies where long term relief is much less than 50%. There were also many studies that demonstrated an increase in fertility after excision treatment.

As laparoscopic technology started in gynecology, the equipment was crude and surgeons were learning a new technique. Because of the equipment and skill limitations, shortcuts in various procedures were taken. Conversion from excision to cautery was a universal change in the treatment of this disease. Excision via laparoscopy is very technical and time consuming compared to cautery or laser. This technique shift had a dramatic effect on the fertility research of the time (see below). Studies tried to compare treated and non-treated groups, yet with cautery, the disease was not cured and the two groups were the same. It’s no wonder that these studies of the 70’s and 80’s showed no difference in outcomes for fertility and less optimal results for pain. This unfortunately is an example where technological advances have actually dramatically hurt patient care. Three generations of gynecologists later, excision for endometriosis is a rarity in contrast to pre-laparoscopy where it was universal.

Recurrence: In contrast to what patients read on the internet, or told by physicians, endometriosis is most likely NOT a recurrent disease. We have re-operated on many patients in 18 years for other reasons with rare findings of recurrent disease. Most, >99% of gynecologists in the US, use destructive methods at surgery (cautery and laser) in an attempt to “destroy” visible lesions. In most cases, there are numerous lesions present, making this spot treatment very difficult. Microscopic lesions can be missed, and the tissue changes color with cautery and it is impossible to know if the entire lesion has been destroyed, especially for deeper lesions. With excision, the entire area including all the lesions extending out to normal peritoneum is removed. If lesions are deep, we recognize it as we undermine the peritoneum and can completely remove it. We believe a person gets all the endometriosis they are going to have by the mid teens and from there lesions go through their life-cycle and if removed are gone forever. No new disease is forming. What has been observed though by other physicians over time is recurrent pain in patients with endometriosis and when re-operated after a prior cautery procedure, lesions are seen. We see this also in nearly all patients after cautery and laser procedures and there is disease present but it is obvious that some of the disease has been treated before, just not completely. The appropriate word therefore is persistence not recurrence. We therefore feel that excision is curative for endometriosis. Pain could recur but endometriosis would be an unlikely cause of the problem. Hence pain does not equal endometriosis.

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